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Diagnosing Early
Interceptive Orthodontic
Problems – Part 1
A Peer-Reviewed Publication
Written by:
Michael Florman, DDS
Rob Veis, DDS
Mark M. Alarabi, DDS, CECSMO
Mahtab Partovi, DDS

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Educational Objectives
Upon completion of this course, the clinician will
be able to do the following:
1. Be knowledgeable about normal growth and
development of the dentition and its phases.
2. Be knowledgeable about the early treatment
examination and the records that are required
for this examination.
3. Understand the factors and potential prob-
lems to consider during the early treatment
examination.
4. Be knowledgeable about the fixed and remov-
able appliances that can be used as space
maintainers and habit breakers during the
mixed dentition phase.
5. Be able to treat certain early treatment
problems with removable appliances.
Abstract
It is important to have a clear picture of how a child
is changing dentally and skeletally throughout his
or her growth period. In fact the American As-
sociation of Orthodontists recommends that every
child have an orthodontic examination by the age
of seven. The early treatment examination in the
mixed dentition enables the practitioner to identify
problems at an early stage, and to determine when
to commence treatment and/or refer patients to an
orthodontist. Things to look for during a mixed
dentition examination include crowding of perma-
nent teeth, excessive overjet or overbite, missing
primary teeth needed for space maintenance, su-
pernumerary teeth, skeletal discrepancies, habits,
airway problems, and eruption path problems.
Introduction
This continuing dental education article is being
written to describe the need for early examination
and diagnosis of malocclusions in growing chil-
dren. A short review of growth and development
will be presented, along with a description of the
stages of tooth eruption. After completing this
course, the reader will have a clearer understand-
ing of problems associated with children in the
mixed dentition stage of development.
The American Association of Orthodontists
recommends that every child have an orthodontic
examination by the age of seven. By then, the maxil-
lary and mandibular first molars, lateral incisors,
and central incisors should have erupted. This article
will describe what practitioners should be looking
for during an early treatment examination in the
mixed dentition and aid them in determining what
they should treat and/or when they should refer.
This article has been broken into two parts. Part
1 will include a discussion of the mixed dentition
examination, records, tooth eruption sequence,
growth and development, primary teeth as space
maintainers, normal eruption of permanent teeth,
delayed eruption of permanent teeth, over-retained
primary teeth, and supernumerary teeth.
Part 2 will cover: excessive deep bites, cross-
bites, anterior crossbites, class III skeletal and
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dental problems, crowding in the mixed denti-
tion, excessive spacing, open bites and class II
skeletal or dental problems.
The Mixed Dentition
Orthodontic Examination
When performing a mixed dentition examination,
the main goal is to determine whether there is need
for interceptive orthodontic measures that will
allow for the eruption of all the permanent teeth.
The earlier in the mixed dentition stage a problem
is diagnosed and corrected, the better off patients
will be as they continue to grow. When performing
an interceptive orthodontic examination, the fol-
lowing records are needed.
Records
Study Models
Study models are necessary because they allow you
to evaluate the occlusion outside of the patient’s
mouth. For example, abnormal wear patterns and
crossbites can easily be seen. Study models also al-
low the practitioner to perform a mixed dentition
analysis. Many mixed dentition analyses exist,
such as the Tanaka and Johnston and Moyer’s pre-
diction values. An accurate bite registration must
also be taken as part of this record.
Radiographs
Panoramic Radiograph
In the mixed dentition phase, the panoramic radio-
graph is useful for seeing permanent erupting teeth,
crowding of teeth, space or lack of space between
teeth, eruption paths, third molars, supernumerary
teeth, and root apex formation (which is used to
determine the patient’s dental age). Using a pan-
oramic radiograph is like seeing the world through
a wide-angle lens, as compared to looking through
a small looking glass, which could be considered
analogous to full-mouth series of radiographs.
Lateral Head Film (Cephalometric Radiograph)
Lateral head films are necessary when evaluating
growing children to evaluate dentofacial propor-
tions. As teeth erupt and growth occurs, the teeth
relationships (within the jaws and skull) are part of
a much bigger picture only visible with a cepha-
lometric film and the appropriate cephalometric
tracing. In the mixed dentition, the following
guidelines are designed to help in the decision pro-
cess on when a cephalometric film is indicated.
Class II Patients:
Patients presenting with Class II dental relation-
ships such as a distal step in primary second molars.
Patients with Class II relationships of per-
manent molars.
Patients who have a significant positive overjet
and/or patients with mandibular retrusive profiles.
Class III Patients:
Patients with Class III relationships of perma-
nent molars.
 Patients who have a mesial step of primary
second molars.
Patients who have a significant negative
overjet (underbite).
Patients who have a protrusive profile of the
mandible or retrusive profile of the maxilla.
Airway problems:
Airway problems diagnosed in children with open
mouth breathing tendencies, such as turned up noses,
allergic salute (wiping the nose with the hand in an
upward swipe), or other medical history findings.
Vertical relationship problems:
Vertical relationship problems such as open bites
associated with habits, airway problems, verti-
cal skeletal growth problems, or patients with lip
incompetency(lips do not touch or seal at man-
dibular rest).
Serial Lateral Head Films
Serial lateral head film radiographs are useful when
monitoring growth in children with Class II or
Class III tendencies, beginning at the first visit you
diagnose them. They are also useful in comparing
what orthodontically has really occurred after
patients have been treated, by comparing pre- and
post-treatment films.
Photographs
It is recommended that a full series of orthodontic
photographs is taken for all patients. There is a
proper way to take photographs, along with a way
to retract soft tissues to capture vital anatomy, such
as molar relationships.
The standard orthodontic photographs consist of
eight pictures. Extraoral Photos: profile, frontal facial
smiling, frontal facial at rest. Intraoral Photos (teeth in
occlusion): maxillary occlusal, mandibular occlusal,
right and left buccal dental, and frontal dental.
There are other useful photos one can take
when documenting an examination. For example,
a patient with a tooth interference that causes a
shift when intercuspation occurs can be docu-
mented by photographing the midlines at rest and
with the teeth apart. When the patient occludes,
the midlines will change, demonstrating the shift.
Close-up shots of individual teeth are also use-
ful when documenting chips or decalcifications
that you may be blamed for in the future after
orthodontic treatment has been completed.
Other Records
Other records may also be needed, depending on
the oral examination, such as anterior-posterior
films (AP films) (for transverse analysis), cone-
beam 3-D imaging films (the new frontier in radi-
ology), and/or occlusal films.
Growth and Development
Eruption of Teeth
By definition, the mixed dentition has both
primary and permanent teeth in function. The
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primary dentition ends with the first eruption of
a permanent tooth. It is not age dependent. The
mixed dentition phase ends when there are no lon-
ger any primary teeth in the mouth. This becomes
the permanent dentition.
Prior to age five, most children will have only
their primary teeth. At ages six to seven, the first
permanent molars will erupt. Permanent centrals
will usually erupt between the ages of six and seven.
Lateral incisors will usually erupt between the ages
of seven and eight. This sets the stage for future
eruption of the remaining twelve permanent teeth
(permanent maxillary and mandibular cuspids,
first and second premolars) between the ages of ten
and eleven. At twelve years of age, the four second
permanent molars erupt. For those who have wis-
dom teeth, they erupt by age twenty in most cases.
The ages stated above are just basic guidelines.
It is important to know that chronological age does
not follow dental age, nor does it correlate with
children’s height, weight, or mental development.
This is a common question asked by parents.
Growth of the Maxilla and Mandible
Growth in the cranial base pushes the maxilla
forward, as well as active growth in the maxillary
sutures that is responsible for the passive displace-
ment of the maxillary process. As the maxilla is
translated downward and forward, bone is added
at the sutures and in the tuberosity area posteriorly,
while at the same time surface remodeling removes
bone from the anterior surfaces. For this reason, the
amount of forward movement of anterior surfaces
is less than the amount of displacement. In the
roof of the mouth, however, surface remodeling
adds bone, while bone is resorbed from the floor
of the nose. The total downward movement of the
palatal vault, therefore, is greater than the amount
of displacement. Between the ages of seven and
fifteen, one-third of the total forward movement
of the maxilla can be accounted for by this passive
displacement. It can be concluded that two-thirds
of the growth during that time is via active growth
at the sutural level. If cranial or facial bones are
mechanically pulled apart at the sutures, new bone
will fill in, and the bones will become larger than
they would have been otherwise. If a suture is
compressed, growth at that site will be impeded. It
is imperative to understand the growth sequence
in order to properly diagnose maxillary excess or
deficiency and to treat orthopedically.
Mandibular growth occurs by both endochon-
dral proliferation at the condyle and apposition
and resorption of bone at surfaces. The mandible
is formed from Meckel’s cartilage. The two halves
of the mandible are united at the anterior midline
by a suture at the symphysis. Further growth
continues at this suture until it ossifies during the
first year of life. Throughout growth the mandible
is translated downward and forward. It seems that
the mandible is translated in space by the growth
of muscles and other adjacent soft tissues and
that addition of new bone at the condyle occurs
in response to the soft tissue changes. On average
the ramus height increases 1 to 2 mm per year and
body length increases 2 to 3 mm per year.
The maxilla and mandible grow in all three
planes of space, in the following sequence: width,
length, and then height. In both sexes, growth in
vertical height of the face continues longer than
growth in length, with the late vertical growth
primarily in the mandible. Increase in facial
height and concomitant eruption of teeth continue
throughout life.
Primary Teeth Act as Space Maintainers
The primary cuspids and first and second primary
molars act as space maintainers for the permanent
erupting cuspids and premolars. The permanent
premolars are smaller than the primary molars
they replace. In the maxilla an average of 1.5 mm
of space exists and in the mandible 2.5 mm due to
the differences in size of these teeth. This space is
called Leeway space. The primary cuspids and first
and second primary molars not only act as space
maintainers for the permanent cuspids and first and
second premolars, but also act as a guide for the per-
manent teeth to follow when erupting (Figure 1).
Figure 1. Primary Teeth as Space Maintainers
Space Maintenance
It is essential that children be evaluated for miss-
ing primary teeth in order to determine if any
space maintenance is necessary. As a general rule
of thumb, it is recommended that all space created
by a missing primary tooth should be maintained.
When in doubt, maintain space.
If there is an early loss of a primary molar
and the first permanent molar has erupted, space
maintenance must be employed as soon as pos-
sible. Doing so will prevent the first permanent
molar from drifting mesially. If the first molar is
allowed to drift mesially, it will not only eat up the
Leeway space, but it can potentially interfere with
the eruption of the premolars or canines.
Posterior Space Maintenance
Space maintainers are very important to keep this
Leeway space intact until eruption of the perma-
nent teeth occurs. There are two basic categories of
space maintainers: fixed and removable. As a rule,
fixed appliances are generally used as space main-
tainers. The two types are unilateral and bilateral.
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The unilateral space maintainer can be used in
very young children who have lost a single primary
posterior tooth but only when you are sure that
the successor tooth will not erupt for many years.
Otherwise when using a space maintainer consider
using a bilateral space maintainer because:
1. If a permanent tooth is erupting a properly
designed bilateral space maintainer will not
cause you to have to remove the new appliance
you just placed.
2. If there is need for other space maintenance on
the other side of the arch, a bilateral appliance
would be a better choice.
Figure 2 demonstrates a unilateral space
maintainer used in the arch with the opposite side
left untreated. Perhaps a better appliance choice
would have been one that would have maintained
space throughout the entire arch.
Figure 2. Unilateral Space Maintainer
Here are some questions that should be asked
when evaluating whether there is enough space in
the mixed dentition patient:
How much anterior mandibular crowding is
present (teeth numbers 23, 24, 25, and 26)?
Is there enough Leeway space to accommodate
the lower crowding plus the unerupted permanent
teeth (cuspid and premolars)?
How much anterior maxillary space (or crowd-
ing) is present (teeth numbers 7, 8, 9, and 10)?
This is where the mixed dentition analysis and
the panoramic radiograph become useful.
Analyses such as the Tanaka and Johnston meth-
od measure one half of the mesiodistal width of the
four lower incisors. Then by adding 10.5 mm to this
number the space needed for the mandibular canine
and premolars in one quadrant can be estimated.
Add 11 mm to estimate the space required for the
maxillary canine and premolars in a maxillary quad-
rant. This method has good accuracy for children of
European descent. This method will overestimate
the required space for Caucasian females in both
arches and underestimate the space required in the
lower arch for African-American males.
An excellent reference for the mixed denti-
tion analysis can be found in The Practice Build-
ing Bulletin, Volume IV, Issue XIX, located at
www.appliancetherapy.com, under practice
building bulletins.
5
 The lower lingual holding arch (LLHA) in
the mixed dentition is readily used to maintain
the Leeway space in children with minor to
moderate crowding (Figure 3). Note the Leeway
space maintained on the lower right segment
between the first premolar and the cuspid.
Figure 3. Lower Lingual Holding Arch
The transpalatal arch appliance is used in the
maxillary arch as a bilateral space maintainer
(Figure 4).
Figure 4. Transpalatal Arch Appliance
If maximum anchorage is needed, a Nance
button can be added to a maxillary appliance
which touches the palate, preventing mesial
movement of the maxillary molars (Figure 5).
Figure 5. Nance Button Appliance
The following case demonstrates a maxillary
arch with no crowding and with a normal erup-
tion pattern (Figure 6). In the mandibular arch
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(Figure 7), there is minor crowding that will be
resolved by using the Leeway space that is main-
tained by using a fixed lingual holding arch.
Figure 6. Maxillary Arch with No Crowding
When a patient receives a fixed lower lingual
holding arch, it maintains the space that the pri-
mary cuspids and primary molars are occupying.
Once exfoliation occurs, the anterior crowd-
ing can be distalized into the Leeway space.
From the mixed dentition analysis, the follow-
ing were labeled:
A. Corrected lateral position, which corrects
for excess space or crowding in the ante-
riors, demonstrating the space the laterals
will occupy when uncrowded and properly
aligned.
B. True available space, which is measured
from the mesial of the first molar to the the
corrected later position (Figure 7).
Figure 7. Mandibular Arch with Minor Crowding
In Figure 8, the panoramic radiograph
demonstrates enough Leeway space for the
permanent teeth to erupt. Note, it is difficult
to see the crowding in the anterior teeth on a
panoramic film.
Figure 8. Panoramic Radiograph Demonstrating
Sufficient Leeway Space
Anterior Space Maintenance
There are three categories of anterior space
maintainers: fixed, removable-functional, and
removable-static. Anterior space needs to be
maintained for esthetics, normal speech and
phonetic development, and to allow normal oral
maxillofacial development.
The best fixed appliance for anterior space
maintenance in arches that do not need arch de-
velopment is the Groper appliance (Figure 9).
Figure 9. Groper Appliance
When arch development is needed, remov-
able-functional appliances like the Schwarz can
be used, delivering esthetics during arch devel-
opment (Figure 10).
Figure 10. Maxillary Schwarz Appliance
The next category, removable-static, is rep-
resented by Hawley-type appliances that have
an artificial tooth placed. As permanent teeth
erupt, adjust the acrylic to accommodate the
needed space. Its main use is in trauma cases
and cases that have congenitally missing teeth
(for example, lateral incisors). A labial bow can
be used to add retention if desired (Figure 11).
Figure 11. Hawley Flipper
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Delayed Eruption
Children who have a single tooth that is not
erupting comparably to the tooth on the op-
posite side (same arch) should be watched and
reevaluated in (three- to six-month) increments
to determine if interceptive treatment is needed.
There are many possible causes for the delay
of the eruption. One of the most common is
an earlier trauma to the region. It is sometimes
necessary to perform surgical exposure to gin-
gival tissue that may be holding up the eruption
process. Today these procedures are quite easy,
using laser technology to open a small window
in the tissue that will allow the teeth to erupt.
In cases where the bone is holding up the erup-
tion, it is best to have an oral surgeon remove the
bone, leaving a window for the tooth to erupt
through. It is rare that these teeth are ankylosed,
or have lost their eruption potential.
Figures 12 and 13 demonstrate tooth number
9 almost erupted, with tooth number 8 delayed.
The primary right central incisor is still present
in this patient with a complete root.
Figure 12. Panoramic Radiograph Showing
Delayed Eruption
Figure 13. Delayed Eruption of Tooth Number 8
In many cases, after teeth have been surgi-
cally exposed and still do not erupt on their own,
a bonded button and some elastic force anchored
to either a removable appliance or fixed brackets
may be needed to facilitate the movement.
If no movement occurs after forces have
been applied for a short period, the tooth may
be ankylosed. This will require some form of
luxation, which hopefully will free up the tooth
and allow the eruption to occur.
Retained Primary Teeth
Retained primary teeth need to be extracted to
allow for the eruption of the permanent succes-
sors (Figure 14). It is not exactly known why
some primary teeth do not exfoliate, but in the
event you see a primary tooth with no mobility
and the successor stuck below it, you should
extract the tooth to allow for normal eruption.
Figure 14. Retained Primary Teeth
Some of the mesial root of the primary first molar did not resorb and can
be clearly seen on the radiograph.
Supernumerary Teeth
Diagnosis of supernumerary teeth is best made
early, and treatment planning their extraction
should begin as soon as an oral surgeon deems it
appropriate. In many instances, the oral surgeon
may elect to wait some time before removing
them in order to prevent damaging adjacent
teeth. Set up a consult as soon as supernumer-
ary teeth are discovered. If you are planning on
moving teeth orthodontically, supernumerary
teeth need to be removed prior to starting treat-
ment. The most frequent place for supernumer-
ary teeth to be present is in the maxilla. Figure
15 illustrates three supernumerary teeth.
Figure 15. Supernumerary Teeth
Habits/Environment/Speech Problems
Detection of poor habits and speech problems
needs to be addressed as early as possible. In some
instances, excessive environmental forces (for
example, playing a musical instrument) can alter
growth if forces are applied over long periods of
time. The habits of children, both nocturnal and
during the daytime, can alter tooth positions and
skeletal development in some cases. Practitioners
should examine all children for signs of habits
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and their associated actions that may change the
way an individual child grows.
Children with airway obstruction, present-
ing with enlarged adenoids or tonsils, should be
evaluated for surgical removal of these tissues.
Find an ENT in your area who will help you di-
agnose and confirm possible airway obstruction
and will take the measures necessary to perform
the surgeries when needed. In undiagnosed
airway obstruction, jaws can grow narrow, due
to the open mouth breathing positions. The
muscles of the face constrict the jaws and can
lead to a condition called Adenoid Facies and
Narrow Face Syndrome.
If it is suspected that a child may have an
obstructive airway, it is recommended that the
patient see a specialist and have a sleep study.
The dangers of obstructive sleep apnea are well
documented in both children and adults. Dental
practitioners may be the first line of defense in
diagnosing these problems. Symptoms children
who have obstructive sleep apnea exhibit in-
clude restlessness, inability to do well in school,
irritability, etc. For an excellent article on sleep
apnea, go to www.appliancetherapy.com and
download the Practice Building Bulletin on
sleep apnea. Articles on sleep apnea can also be
found at www.ineedce.com.
Speech Problems, Tongue Position,
or Thrust Problems
Tongue position problems can cause dental
anterior open bites, which if not treated early
can lead to unfavorable skeletal growth. Normal
speech development is virtually impossible if the
tongue is not able to position properly against
the palate and teeth.
Students of early treatment often debate
whether the tongue thrust is truly a thrust or a
position the tongue takes to create a seal needed
for swallowing. Some patients have vertical
growing skeletal patterns that can result in open
bites. Some children with airway problems who
are forced to breathe through their mouths can
also exhibit narrowing of arches, resulting in
transverse discrepancies with open bites, affect-
ing tongue position. Regardless, tongue thrust
or tongue position problems are very important
to diagnose and correct.
First, assess if there are any underlying speech
problems. If so, refer the patient for therapy right
away. Attempting to correct a speech problem
later in life results in poorer prognoses.
Then ask the patient to swallow as you gen-
tly force the lips open with a gloved finger to see
if the tongue is pushing forward. It instantly
becomes obvious that the tongue is filling the
space, and now a diagnosis needs to be made to
determine if this is a simple tongue thrust or a
more complex problem involving the airway or
vertical skeletal growth. Figure 16 illustrates the
tongue at rest in a patient with a tongue thrust
habit. Even when the patient is not swallowing
Figure 16. Tongue Thrust Habit
Figure 17. Bonded Tongue Crib Prior to Treatment
Figure 18. Bonded Tongue Crib During Treatment
(posing for a picture), the tongue decides to rest
in this position maintaining the open bite.
Tongue appliances can be both fixed and
removable. Fixed appliances use two bands ce-
mented on either the permanent first molars or
the primary second molars.
Some practitioners use removable appliances
for tongue problems, but to work, the appliance
needs to be worn all the time, even when eating.
Children adapt quickly to speaking normally
and are instructed to place their tongues up against
the anterior hard palate when swallowing.
After approximately six to eight months,
remove the appliance and evaluate whether the
problem has been resolved. When using a fixed
tongue crib, it will usually work within this time
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frame. Because habits can be difficult to correct,
it is necessary to evaluate the patient within
three months after the appliance therapy ceases,
in order to make sure that the habit is actually
broken and the open bite does not return. If the
problem does return, replace the appliance for
another four months, and reevaluate.
Figures 17 shows a bonded tongue crib prior
to treatment. Figure 18 demonstrates the open
bite closing. Note, in most cases the open bite
will close most of the way, but in this case, ad-
ditional intervention such as fixed braces will
be needed.
Another appliance that is used to aid in training
the tongue from moving forward is the transpalatal
spinner. The patient is informed that every time
they swallow, they are to reach back with the tip of
the tongue upon swallowing (Figure 19).
Figure 19. Transpalatal Spinner
Figure 20 illustrates a removable Hawley
tongue crib appliance. In order for this appli-
ance to work, it needs to be worn all day and
night except when eating.
Figure 20. Removable Hawley Tongue Crib
Digit and Other Habits
Digit (finger) habits can include sucking, nail
biting, and other habits including pen/pencil
biting. They are also best solved by using fixed
bonded appliances. Leave the appliance in for
approximately six months, and then remove it
and evaluate if the child is continuing to place
digits in his or her mouth.
9
 With digit habits, the bonded appliance
alters the way the digit feels when inserted in
the mouth. The bluegrass roller is an excellent
appliance for eliminating digit habits (Figure
21). After successfully wearing a tongue or digit
habit appliance and eliminating the tooth mov-
ing forces created by the digit, the natural forces
from the muscles in the cheeks and lips will cor-
rect the protrusion in most cases.
Figure 21. Bluegrass Roller Appliance
Summary
In accordance with the recommendations of the
American Association of Orthodontists, the
early treatment examination of the mixed denti-
tion should be performed by age seven. During
this examination radiographs, models and orth-
odontic photographs are required. Additional
records may also be necessary depending on the
patient. During the examination, it is important
to consider primary teeth as space maintainers
and to identify any problems that may require
intervention. Potential problems can include
early loss of primary teeth, retained primary
teeth, delayed eruption of permanent teeth,
supernumeraries, and habits. Early assessment
enables the early identification of problems,
intervention and optimal timing of referral and/
or treatment for the patient.
References
1 Proffit WR. Contemporary Orthodontics, Fourth
Edition, Mosby, 2007.
2 Ibid.
3 Ibid.
4 Altherr ER, Koroluk LA, Phillps C. The influence of
gender and ethnic tooth-size differences on mixed
dentition space analysis. Am J Orthod Dentofac
Orthop, in press.
5 Proffit WR. Contemporary Orthodontics, Fourth
Edition, Mosby, 2007.
Authors Profiles
Michael Florman, DDS
Dr. Florman received his den-
tal degree from the Ohio State
University and completed his
10
post graduate training in Orthodontics at New
York University. Dr. Florman is a Diplomate
of the American Board of Orthodontics, and
has been practicing dentistry since 1991. He
has authored over forty scientific publications
in the field of dentistry and medicine, and is an
active clinical advisor to many pharmaceutical
and dental companies. He is a member of the
American Dental Association, California Den-
tal Association, and the American Association
of Orthodontists
Rob Veis, DDS
Dr. Rob Veis began 24 years ago as a general
dentist, and taught for twelve years at the Uni-
versity of Southern California as a Clinical Pro-
fessor in Restorative Dentistry. Dr. Veis lectures
for the AGD/California masters program. He
also lectures internationally, on the integration
of orthodontics and appliance therapy into the
general practice on behalf of Space Maintainers
Laboratories where he has been a member of the
teaching staff since 1990. He is coauthor of the
comprehensive textbook Principles of Appliance
Therapy for Adults and Children, and author of
several Practice Building Bulletins. Dr. Veis is
a member of the California Dental Association
and the Academy of General Dentistry.
Mark Alarabi, DDS, CECSMO
Dr. Al-Arabi obtained his dental degree from
the University of Tishreen, Syria in 1996.
He received his training in Orthodontics and
Dento-Facial Orthopedics at the University of
Aix-Marseille II earning a Certificate of Special
Studies in Clinical Orthodontics (CECSMO)
in 2002, and is a former member of the French
Society of Dento-Facial Orthopedists and the
French Society of Bioprogressive. Dr. Al-Arabi
joined the faculty at Jacksonville University in
July 2003. He is a member of the American As-
sociation of Orthodontists.
Mahtab Partovi, DDS
Dr. Partovi received her dental degree from
New York University College of Dentistry. Dr.
Partovi is presently a resident at Jacksonville
University, School of Orthodontics, and is a
member of the American Dental Association
and the California Dental Association.
Disclaimer
The authors of this course have no commercial ties
with the sponsors or the providers of the unrestricted
educational grant for this course, except for Dr. Rob
Veis who is an instructor for the Appliance Therapy
Group and the SMILE Foundation.
Reader Feedback
We encourage your comments on this or any
PennWell course. For your convenience, an
online feedback form is available at www.
ineedce.com.
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 Questions
1. The American Association of 11. If there is early loss of a
Orthodontists recommends that primary molar and the first
every child have an orthodontic permanent molar has erupted,
examination by age seven. maintaining the space as soon
a. True as possible will _________.
b. False a. create extra space for wisdom teeth
b. prevent eruption of permanent premolars
2. The main goal of a mixed denti- c. prevent the first permanent molar from
tion examination is _________. drifting mesially
d. none of the above
a. to determine whether there is a need for
multiple extractions 12. The unilateral space maintainer
b. to determine whether there is a need for should be used in _________.
interceptive orthodontic measures a. very young children who have lost a
c. to assess the patient’s caries experience single primary posterior tooth
d. none of the above b. very young children when you are sure
the successor tooth will not erupt for
3. The records needed when many years
performing an interceptive c. children whose permanent bicuspids
orthodontic examination have already erupted
d. a plus b
are _________.
a. panoramic and cephalometric 13. When evaluating space in the
radiographs mixed dentition, the _________
b. study models should be evaluated.
c. orthodontic photographs a. sufficiency of Leeway space
b. amount of mandibular crowding
d. all of the above
c. amount of anterior maxillary spacing
or crowding
4. Serial lateral head films are
d. all of the above
useful when patients have
Class I tendencies. 14. The Tanaka and Johnston method
a. True will overestimate the required
b. False space for Caucasian females.
a. True
5. Other records that may also b. False
be needed for an interceptive
15. The lower lingual holding arch
orthodontic examination is readily used _________.
include _________. a. in the fully erupted permanent dentition
a. anterior-posterior films to maintain the Leeway space
b. cone-beam 3-D images b. in the mixed dentition to maintain
c. occlusal films the Leeward space in children with
d. all of the above severe crowding
c. in the mixed dentition to maintain the
6. Chronological age correlates Leeway space in children with mild to
with a child’s dental age, height, moderate crowding
d. none of the above
weight and mental development.
a. True 16. The transpalatal arch is
b. False used _________.
a. in the maxillary arch as a bilateral
7. Lateral incisors usually erupt space maintainer
between the ages of _________. b. in the maxillary arch as a unilateral
a. four and five space maintainer
b. five and six c. in the mandibular arch as a bilateral
c. six and seven space maintainer
d. seven and eight d. a and c
17. The addition of a Nance
8. During growth, the amount
of forward movement of button to a maxillary
appliance _________.
the anterior surfaces of the a. prevents distal movement of the
maxilla is less than the amount maxillary molars
of displacement. b. prevents mesial movement of the
a. True maxillary molars
b. False c. prevents tongue thrust
d. all of the above
9. Late vertical growth occurs
18. The three categories of ante-
primarily in the _________. rior space maintainers are the
a. symphysis fixed-functional, fixed-static
b. maxilla and removable.
c. mandible
a. True
d. tuberosity b. False
10. The space maintained by the 19. According to the authors, the
primary cuspids and molars Groper appliance is the best
for the permanent erupting appliance for _________.
cuspids and premolars is a. missing posterior teeth in arches that
need arch development
known as the _________. b. missing anterior teeth in arches that need
a. Leeward space arch development
b. Leeway space c. anterior space maintenance in arches that
c. Maintained space do not need arch development
d. none of the above d. a and b
www.ineedce.com 11
20. Removable-functional appli-
ances are used when _________.
a. arch development is needed
b. arch development is not needed
c. the patient is noncompliant
d. none of the above
21. Hawley appliances are
examples of _________.
a. fixed appliances
b. removable-static appliances
c. removable-functional appliances
d. none of the above
22. One of the most common
causes for delayed eruption
of a single tooth when the
contralateral tooth has erupted is
earlier trauma to the region.
a. True
b. False
23. A bonded button and some
elastic force can be used to
facilitate movement after surgical
exposure of an erupted tooth.
a. True
b. False
24. Retained primary teeth ______.
a. can be left in place until they
eventually exfoliate
b. need to be extracted to allow for eruption
of the permanent successors
c. are of no consequence
d. none of the above
25. The most common
place for supernumerary
teeth is _________.
a. the mental region of the mandible
b. adjacent to the submandibular
salivary glands
c. the maxilla
d. all of the above
26. Children’s habits can
alter tooth positions and
skeletal development.
a. True
b. False
27. In undiagnosed airway obstruc-
tion in children, _________.
a. the jaws can grow narrow
b. the muscles of the face constrict the jaw
c. the patient may exhibit restlessness
and irritability
d. all of the above
28. Tongue position problems and
tongue thrust can cause anterior
open bites.
a. True
b. False
29. When using a fixed tongue
crib, the problem has usually
been resolved after wearing the
appliance for _________.
a. two to three months
b. three to six months
c. six to eight months
d. nine to twelve months
30. Digit habits are best solved
by _________.
a. using removable appliances
b. using fixed bonded appliances
c. using bitter aloe
d. none of the above
 ANSWER SHEET

Diagnosing Early Interceptive Orthodontic Problems — Part 1

Name: Title: Specialty:
Address: E-mail:
City: State: ZIP:
Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course.
2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question.
5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to
PennWell Corp.

Educational Objectives Mail completed answer sheet to

1. Be knowledgeable about normal growth and development of the dentition and its phases. Academy of Dental Therapeutics and Stomatology,
2. Be knowledgeable about the early treatment examination and the records that are required for A Division of PennWell Corp.
this examination. P.O. Box 116, Chesterland, OH 44026
3. Understand the factors and potential problems to consider during the early treatment examination. or fax to: (440) 845-3447
4. Be knowledgeable about the fixed and removable appliances that can be used as space
maintainers and habit breakers during the mixed dentition phase. For immediate results, go to www.ineedce.com
5. Be able to treat certain early treatment problems with removable appliances. and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
Course Evaluation (440) 845-3447, (216) 398-7922, or (216) 255-6619.
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5
to Poor = 0. P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
1. Were the individual course objectives met?
Objective #1: Yes No Objective #3: Yes No Objective #5: Yes No If paying by credit card, please complete the
Objective #2: Yes No Objective #4: Yes No following: MC Visa AmEx Discover

2. To what extent were the course objectives accomplished overall? Acct. Number: ____________________________
5 4 3 2 1 0 Exp. Date: _____________________
3. Please rate your personal mastery of the course objectives. Charges on your statement will show up as PennWell
5 4 3 2 1 0
4. How would you rate the objectives and educational methods?
5 4 3 2 1 0
5. How do you rate the author’s grasp of the topic?
5 4 3 2 1 0
6. Please rate the instructor’s effectiveness.
5 4 3 2 1 0
7. Was the overall administration of the course effective?
5 4 3 2 1 0
8. Do you feel that the references were adequate?
Yes No
9. Would you participate in a similar program on a different topic?
Yes No
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________
___________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________
___________________________________________________ AGD Code 373

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER
The authors of this course have no commercial ties with the sponsors or
the providers of the unrestricted educational grant for this course, except
Dr. Rob Veis who is an instructor for the Appliance Therapy Group and the
SMILE Foundation.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational
grant from Appliance Therapy Group. No manufacturer or third
party has had any input into the development of course content. All
content has been derived from references listed, and or the opinions
of clinicians. Please direct all questions pertaining to PennWell or the
administration of this course to Machele Galloway, 1421 S. Sheridan
Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be
sure to complete the survey included with the course. Please e-mail all
questions to: macheleg@pennwell.com.
INSTRUCTIONS
All questions should have only one answer. Grading of this
examination is done manually. Participants will receive confirmation
of passing by receipt of a verification form. Verification forms will be
mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or
companies mentioned in this course and expressed herein are
those of the author(s) of the course and do not necessarily reflect
those of PennWell.
Completing a single continuing education course does not provide
enough information to give the participant the feeling that s/he is
an expert in the field related to the course topic. It is a combination
of many educational courses and clinical experience that allows the
participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions
correctly) on the examination will receive a verification form verifying
4 CE credits. The formal continuing education program of this sponsor
is accepted by the AGD for Fellowship/Mastership credit. Please
contact PennWell for current term of acceptance. Participants are
urged to contact their state dental boards for continuing education
requirements. PennWell is a California Provider. The California
Provider number is 3274. The cost for courses ranges from $49.00
to $110.00.
Many PennWell self-study courses have been approved by the Dental
Assisting National Board, Inc. (DANB) and can be used by dental
assistants who are DANB Certified to meet DANB’s annual continuing
education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s
Recertification Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any
exam. Please contact our offices for a copy of your continuing
education credits report. This report, which will list all credits earned
to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can
request a full refund by contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology,
a division of PennWell

ORTHO10803CED

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